There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry disproportionate burden of HIV; however, their burden of HIV and prevention needs remains unknown in Swaziland. To address this gap, a respondent-driven-sampling survey was completed between August and October, 2011 of 328 FSW in Swaziland. Unadjusted HIV prevalence was found to be 70.3% among a sample of women predominantly from Swaziland with a mean age of 21, which was significantly higher than the general population of women. Just 23.5% reported always wearing condoms with sexual partners in the past month, while rape was common at 40% reporting at least one rape, with torture reported at 53.2%. While Swaziland has a highly generalised HIV epidemic, FSW represent a distinct population with a high burden of HIV compared to other women, according to the authors. These women are understudied and underserved resulting in a limited characterisation of their HIV prevention, treatment, and care needs and only sparse targeted programming. The authors argue that FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioural and structural interventions.
Equity and HIV/AIDS
The authors of this study investigated factors associated with patterns of plural healthcare usage among patients taking antiretroviral therapy (ART) in diverse South African settings. They conducted a cross-sectional study of ART patients in two rural and two urban sub-districts, involving 13 accredited facilities and 1,266 participants selected through systematic random sampling. They used structured questionnaires in interviews and reviewed participant’s clinic records. Results showed that 19% of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. Increased plural healthcare utilisation, inequitably distributed between rural and urban areas, was found to be largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Healthcare expenditure of a catastrophic nature remained a persistent complication. Although plural healthcare utilisation did not appear to influence clinical outcomes, there were potential negative impacts on the livelihoods of patients and their households.
This study aims to demonstrate changes in population level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale up of the national antiretroviral therapy (ART) programme. The authors used data from 2070 deaths of people aged 15–54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Results indicated that, overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53% less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. In conclusions, population-level HIV mortality in Nairobi’s slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalised slum populations in Kenya.
In a previous issue of the Southern African Journal of HIV Medicine, Pillay and Black summarised the trade-offs of the safety of efavirenz use in pregnancy. Highlighting the benefits of the World Health Organisation’s proposed options for the prevention of mother-to-child transmission (PMTCT) of HIV, the authors argued that the South African government should adopt Option B as national PMTCT policy and pilot projects implementing Option B+ as a means of assessing the individual- and population-level effect of the intervention. The authors of this article echo this call and further propose that the option to remain on lifelong antiretroviral therapy, effectively adopting PMTCT Option B+, be offered to pregnant women following the cessation of breastfeeding, for their own health, following the provision of counselling on associated benefits and risks. Here they highlight the benefits of Options B and B+.
To investigate the claim that widespread availability of antiretroviral therapy (ART) may result in sexual disinhibition, including practice of high-risk sexual behaviour, the authors of this study determined the correlates of sexual activity and high-risk sexual behaviour in an ART-treated population in rural and urban Uganda. They studied 329 ART-treated adult patients at two hospitals in western Uganda, collecting data on sexual activity, frequency of condom use, pregnancy, viral load and CD4 counts. Younger age, higher monthly income and being married were associated with being sexually active. Among the sexually active, alcohol consumption and unknown serostatus of partner were significant predictors of high-risk sexual behaviour. The frequency of unprotected sex at the last intercourse was 25.9% and 22.1% among the men and women respectively and was not significantly different. The authors recommend that counselling on alcohol use and disclosure of sero-status may be useful in reducing high-risk sexual behaviour.
In April 2013, the South African government announced that it will offer all HIV-infected pregnant and breastfeeding women antiretroviral (ARV) treatment, regardless of the state of their health. Previously, only pregnant women with significantly weakened immune systems qualified for the drugs. The government is also now supplying HIV-infected pregnant women with a convenient once-a-day tablet. A department of health spokesperson said an increase in access to ARVs will lead to a decline in maternal mortality. Almost half of all maternal deaths in South Africa are caused by HIV-related complications. However, the former director of maternal health at the department of health, Eddie Mhlanga, disagreed, arguing that there is no evidence yet that the government's antiretroviral drug programme has led to a lower chance of pregnant women infected with the virus dying during pregnancy, childbirth or within 42 days thereafter. He said negligence, substandard care and mismanagement in maternal wards would first need to be addressed.
This study reports on a ten-step Nurse Initiation Management of Antiretroviral Treatment (NIMART) rollout intervention in which 45 nurses from 17 primary healthcare centres (PHCs) in Johannesburg, South Africa, were trained and mentored in NIMART to commence patients on antiretroviral treatment (ART). A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. By the end of September 2011, all 17 PHCs were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout and continued to increase by an average of 9 every month, while referral facility initiations decreased by 12 immediately after NIMART and then decreased by an average of 18 every month. In conclusion, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, the authors argue that it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients.
In a study of prevention of mother-to-child transmission of HIV (PMTCT) by triple antiretroviral therapy (ART) in Dar es Salaam, Tanzania (the Mitra Plus study), retrospective viral load testing revealed a high and increasing frequency of detectable viral load during follow-up for two years postnatally in women given continuous ART for their own health suggesting poor adherence. This study explored women’s own perceived barriers to adherence to ART post-delivery so as to identify ways to facilitate better drug adherence. Semi-structured interviews were conducted with 23 of the 48 women who had detectable viral load at 24 months postnatally. Most women in the study did not acknowledge poor adherence until confronted with the viral load figures. Then they revealed multiple reasons for failing to adhere to ART, which included lack of motivation to continue ART after weaning the child, poverty and stigma. PMTCT and ART projects need to address these issues, as well as women’s lack of empowerment. The authors argue that the new World Health Organisation’s proposal to start all HIV-infected pregnant women on lifelong ART regardless of CD4 cell count needs to address the challenging realities of women in resource-poor contexts if it is to be successful.
While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing in sub-Saharan Africa (SSA), systematic reviews to provide a more comprehensive understanding are lacking. In this study, researchers synthesised 42 papers from 13 countries to investigate these factors. They found that predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women’s decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.
This cross-sectional study design was conducted among 753 students drawn from selected departments in Debre Markos University, Ethiopia, using multi-stage sampling technique. A self-administered questionnaire was used to estimate the prevalence of voluntary counseling and testing (VCT) service utilisation and to assess associated factors. A total of 711 students participated in the study, of whom 81.4% had heard about the government’s confidential VCT service, identifying their major sources of information as mass media (73.3%) and health workers (71.1%). Just over half (58.5%) of the study participants had undergone VCT. The researchers identified the major factors for increased VCT service utilisation as knowledge about the availability of antiretrovirals in the VCT site, information about confidentiality, absence of perceived stigma, higher risk perception and knowledge about HIV. Therefore, they argue, actions targeting on these predictors are necessary to effectively enhance the use of the VCT services utilisation.